Affiliated Dermatologists of Virginia

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I hereby AUTHORIZE and give consent to:

To RELEASE healthcare information on the above named patient TO:

If you selected The following dates only, please specify Start Date and End Date:

This authorization to release confidential information may be revoked by me in writing at any time, except to the extent that the action has taken in reliance on it. It shall be effective only long enough to fulfill the specific purpose for which it is given or for sixty days, whichever comes first. No further confidential information will be released without the execution of an additional written statement of consent. I understand that I am not required to give this consent, and that I can refuse without any prejudice to my future treatment at Affiliated Dermatologists of Virginia.

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